I have worked in the administrative sector* of the medical world for many years. My major concern was collecting the monies owed to the facility or the physicians for whom I worked. This involved billing patients, commercial insurance companies, Medicaid and Medicare. During my experience in submitting claims, I quickly learned that your medical record must have documentation to support every charge billed. That introduced me to the problem of discrepancies and omissions in medical charts.

Patients have been told that a physicians' time is very limited, so be sure to prepare your questions ahead of time to expedite your visit. A patient assumes that when he or she talks to the physician, and addresses this list of questions, or problems, this information becomes part of the medical record. Not so. The doctor knows that his services can only be billed for one or two focused diagnoses. Therefore, he will determine which of your ailments or concerns deserves his attention for that visit, and treat you for that. Your medical record will denote that he discussed this diagnosis with you and, perhaps, treated you for it. He will probably not mention anything else that you discussed with him. Occasionally a doctor will ramble a bit in his dictation and add a few observations, but rarely.

Sometimes the doctor will not do his dictation until the end of the day, after he has finished seeing all his patients. He relies on notes he has made on the office visit encounter form, and his memory. Some physicians have very good retention of data, and can do detailed dictation on every patient seen over an eight-hour period. Keep in mind that one physician may see up to 60 patients in a day. Most see less than that, averaging between 24-36.

In my work I would frequently discover that the doctors' dictation had not mentioned a diagnosis that I needed to bill for. I would take a copy of his dictation and a copy of the charge sheet back to him, showing that he wanted me to bill for a service pertaining to a particular diagnosis, but I did not have documentation for it. He would revise his dictation, and that settled the problem.

As people age, they are sometimes bothered by a multitude of problems. When they see the doctor they may complain of more than one problem. If they have been seeing their physician for a period of time, and he is familiar with the patients' history, he may actually treat them for several things during the visit, but limits his charges to the one he will get the most reimbursement for, since he can't charge for all of the things he does. When he does the dictation for that visit, he may fail to mention the additional treatment. This is an omission from the medical record, and does not properly reflect the medical history of the patient.

You are probably thinking that this is just a dollars and cents issue for the doctor, since it seems to be based on how a doctor is limited in what he can bill for his services. Wrong! This is serious business, when it comes to your medical history and could be a dollars and cents issue for you. If you are a young person when you have an onset of multiple symptoms, and you receive treatment for these symptoms over a period of years, there may not be a complete record of it. Then if you should become physically disabled prior to retirement eligibility, you will be required to show documentation of all the ailments and symptoms that have caused that disability. Lack of documentation in your medical record will possibly disqualify you from receiving benefits. Even though your physician may be well acquainted with you and your health issues, he may not be willing to testify in your behalf, where he would be required to acknowledge under oath that he did not accurately record his treatment.

Another problem is, as we age, we may become forgetful. When you are being treated for more than one problem, some unhappy incidences could occur. Unless the doctor noted in your medical record that he gave you some free samples of a new medication for acid reflux, and then later prescribes a medication that induces side effects in people who are using the reflux medication, you may suffer the consequences. Maybe he asks you whether you've used that medication recently, but you have forgotten. Had he mentioned the medication in your previous Progress Note, the incident would never happen. The problem of over-medicating, and adverse reactions is becoming larger and larger due to the availability of "free samples" and inadequate dictation to reflect what medications a patient is using. Modern technology is helping to combat some of the problems with over medicating. Most pharmacies have computer access to a record of any prescriptions filled for you. To protect yourself, always carry a list of every medication, even over the counter cough and cold remedies, indigestion and pain relief, when you visit your doctor.

If you are concerned that your medical record may be lacking important information, ask for a copy of it. You may be charged for the copies. Read through it carefully. If you detect any omissions, take it back to the doctors' office and ask that he revise his notes. If too much time has lapsed since the omission, he may not amend his notes. If you jog his memory, he will be happy to accommodate you. Unless he can specifically recall the incident or information that you find discrepancies in, he will not want to alter the record. Doctors want to be accurate in their notes, and reflect the care and treatment for their patients. But, they also must be careful not to include "second hand" information just to satisfy a patient.

Most of us do not visit the doctor unless we are sick or hurt, and need medical attention. However, there are many who visit the doctor for minor or insignificant ailments because they are lonely, frightened, or paranoid about becoming seriously ill. Some people refer to the later as hypochondriacs. A physician is very busy, with many details to remember. It may surprise you to know that a doctor will permit you to diagnose yourself.

It's true. The physicians' nurse will interview you before he sees you. She will take your vital signs, ask questions and make notes that he will refer to. When he comes in he asks a few questions and proceeds to examine you, based on what the nurse wrote down, and what you are telling him. If he ascertains that there is a particular problem that he needs to explore, then he may recommend further tests, or examinations and treatment. If you ramble and stray off to other symptoms than noted to the nurse, he will let you tell him what you think is wrong, and then treat you for it!

One other thing that patients should be aware of: most clinics and doctors' offices collect deductibles and co pays before you see the physician. If you do not have insurance, the financial counselor may ask you to deposit a sum equal to what the anticipated charges for the visit will be. Read your monthly statement. If you do not get a statement, call the office and request one. Why? If there is a credit (overpayment) on your account, the office may not send you a statement, because they know you will ask for a refund. Under the laws of most states, unless you request a refund, the physicians' office does not have to give it back, and after a required waiting period, can keep any overpayments. Some physicians' offices/clinics have hundreds of thousands of dollars in overpayments drawing interest for them.

Just as it is your responsibility to maintain your health, it is your responsibility to keep track of your medical record, and your patient accounts. What you don't know can hurt you in your pocketbook!